Aldringham Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incidents and accidents were analysed, including identifying potential trends, and measures in place to reduce future risks. Lessons learned were shared with the staff team in group and individual meetings to ensure all staff were aware of any changes required in the support they provided.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Prior to people moving into the service, assessments were undertaken with the input of the person, their representatives and other professionals involved in their care. This helped to ensure a smooth transition. Important information about people was provided to health professionals, for example, if they were admitted to hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

There were systems in place to reduce the risks of abuse, this included training for staff and a policy and procedure. Staff understood their responsibilities in identifying and reporting abuse. A staff member said, “I am aware and got training about different types of abuse, how to identify them and report them to the manager, senior staff or the higher officials.” Records demonstrated concerns of abuse were reported appropriately to external professionals and where required, information was provided to professionals with the remit to investigate safeguarding concerns.

A record of safeguarding was maintained, which demonstrated lessons were learned to reduce future risks.

The provider worked with people to understand and manage risks by thinking holistically. Staff did not always provide care to meet people’s needs that was safe.

Records demonstrated people were involved in the planning of their care, including how risks were being mitigated. A person, who was at risk of falls, showed us their pressure mat and handheld call bell which they always had with them, which made them feel safer.

People’s records included risk assessments and guidance for staff in how risks were reduced, such as risks associated with falls and pressure injury.

Where people required support to move position to reduce the risks of pressure injury developing or deteriorating, the care plans identified the frequency of the repositioning to be done. A member of the management team told us they kept these under review to ensure they were happening as required. However, people’s records did not always show they were being supported to change position in line with the guidance in the care plan. The registered manager and regional manager assured us this would be reviewed and staff reminded of the importance of ensuring people were supported to move position as required. A person’s relative told us their family member was supported to move position and when they visited, “[Staff] come in and check without fail.”

People told us they felt safe, and this was also the feedback received from people’s relatives.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Records showed checks on equipment were undertaken to ensure they were safe for use and fit for purpose, this included mobility equipment and portable electrical appliances. Fire safety was regularly checked and staff had received fire safety training and attended fire drills to keep people safe. Each person’s records had guidance in place relating to the support required if the service needed evacuating. There was a contingency plan in place which provided guidance in an emergency, including gas leak or flood.

The registered manager told us how a secure fence had been put up on the grounds and work was being done to ensure trip hazards were removed to reduce risks, so people could walk around the grounds.

We noted some patio doors in people’s ground floor bedrooms were showing signs of deterioration. The registered manager and regional manager told us quotes had been obtained to replace the doors.

There was an ongoing programme of refurbishment and redecoration.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The registered manager told us how the service was staffed each 24 hour period, including nursing cover on each shift. A tool was used to help the management team to identify the required staffing levels which took into account people’s dependency needs and the layout of the building. The staff levels were kept under review along with the numbers of people using the service and changes in their needs.

Staff were recruited safely, this included making the required checks to ensure staff were of good character and suitable for working in the service.

Staff told us they received the training they needed to meet the needs of the people using the service. Records demonstrated this training included an induction, which incorporated the Care Certificate standards.

People told us they felt there were enough staff to support them. A person said, “They are all kind and there are plenty of them."

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was visibly clean throughout and cleaning schedules showed regular cleaning was carried out. Monitoring and infection control audits supported the management team to identify any shortfalls and address them. A person’s relative said the domestic staff were, “Very good, they clean [family member’s] room every day.”

People’s care plans included guidance for staff about specific infection control support in relation to their needs and conditions to reduce the risks of infection.

There was personal protective equipment (PPE) available, such as disposable gloves and aprons. We observed staff wear PPE where required, and we also observed staff washing their hands.

The service had achieved the highest rating in a local authority food hygiene inspection in April 2025.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People told us they received their medicines when they needed them. A person described the system for medicines administration as, “Perfect.”

People received their medicines as prescribed. Audits and monitoring supported the management team to quickly identify any shortfalls and address them, such as reviewing and updating protocols to guide staff when medicines prescribed to be given as required (PRN) were administered. However, we found 2 protocols with no reference to the medicine, this was rectified immediately.

We sampled medicines that were stored against the records relating to medicines that required specific secure storage and documentation. We found these tallied with each other.

The majority of records which identified where on the body patches were placed, however, we pointed out some did not record this. The management team told us the actions they would be taken to address this.

There had been recent changes in where the medicines were stored, 2 trolleys were secured to the wall in the secure medicine room, 1 was not. The registered manager told us they were looking at where in the room this could be attached. We were assured this was being actioned.

Nursing staff who were responsible for the administration of medicines, were trained to do so safely and their competencies checked. Where people required administration of creams, this was kept under review to ensure people received them as prescribed. A staff member told us, “Residents do receive support with their prescribed creams as we staff ensure that it is applied correctly and regularly whilst also encouraging individuals to feel comfortable and cared for."